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Luai Madanat,1 Melinda Sager,1 Daniel O’Connor,1 Bijaya Thapa,1 Nishant Aggarwal,1 Bipin Ghimire,1 Carl Lauter,1– 4 Gabriel N Maine,5,6 Matthew Sims,1,2,4 Alexandra Halalau1,4 1Internal Medicine, William Beaumont Hospital, Royal Oak, MI, USA; 2Infectious Diseases, William Beaumont Hospital, Royal Oak, MI, USA; 3Allergy and Immunology, William Beaumont Hospital, Royal Oak, MI, USA; 4Oakland University William Beaumont School of Medicine, Rochester, MI, USA; 5Pathology and Laboratory Medicine, William Beaumont Hospital, Royal Oak, MI, USA; 6Pathology, Oakland University William Beaumont School of Medicine, Rochester, MI, USACorrespondence: Luai Madanat, Internal Medicine, William Beaumont Hospital, Royal Oak, MI, USA, Tel +1 248-551-3000, Email Luai.madanat@beaumont.orgBackground: Antibody levels against SARS-CoV-2 can be used as an indicator of recent or past vaccination or infection. However, the prognostic value of antibodies targeting the receptor binding protein (anti-RBD) in hospitalized patients is not widely reported.Purpose: Determine prognostic impact of SARS-CoV-2 antibody quantification at the time of admission on clinical outcomes in hospitalized COVID-19 patients.Methods: We conducted a pilot observational study on patients hospitalized with SARS-CoV-2 infection to determine the prognostic impact of antibody quantitation within the first two days of admission. Anti-nucleocapsid IgG (anti-N) and Anti-RBD levels were measured. Anti-RBD level of 500 AU/mL was used as a cutoff to stratify patients. Spearman’s rank Coefficient (rs) was used to demonstrate association.Results: Of the 26 patients included, those who were vaccinated more frequently tested positive for Anti-RBD (100% vs 46.2%, P = 0.005) with higher median titer level (623 vs 0, P = 0.011) compared to unvaccinated patients. Anti-N positivity was more frequently seen in unvaccinated patients (53.9% vs 7.7%, P = 0.03). Anti-RBD levels > 500 were associated with lower overall hospital length of stay (LOS)(5 vs 10 days, P = 0.046). The analysis employing a Spearman Rank coefficient demonstrated a strong negative correlation between anti-S titer and LOS (rs=− .515, p = 0.007) and a moderate negative correlation with oxygen needs (rs =− .401, p = 0.042).Conclusion: Anti-RBD IgG levels were associated with lower LOS and oxygen needs during hospitalization. Further studies are needed to determine if levels on admission can be used as a prognostic indicator.Keywords: SARS-CoV-2, anti-RBD IgG, anti-nucleocapsid IgG, hospitalized patients, prognosis, outcomes

Background: Cardiovascular implantable electronic device (CIED) technology continue to advance and improve overtime to help in the treatment of various bradyarrhythmia and prevent sudden cardiac death. Trends and types of various CIED insertion has been changing over the past two decades. No recent study has captured trends in procedures related to several categories of implantable devices in United States (US) subgroups. Objective: We conducted a nationwide subcategory analysis of trends in device implants from 2016 to 2019 using the US National Inpatient Sample (NIS) database. Methods: We used data from the NIS between January 2016 to December 2019 on hospitalized adults ≥18 years old undergoing CIED implants and/or device upgrades to study CIED device trends each year stratified by baseline characteristics and comorbid conditions. Linear regression for continuous outcomes and logistic regression for categorical outcomes were used to calculate p-value trends for each subcategory. Results: We found a significant increase in implantation rates of all CIEDs in the US from 2016 to 2019 (150,370 to 159,300). There was a significant increase in dual-chamber compared to single-chamber pacemaker and implanted cardioverter defibrillator devices implanted noted (p Conclusion: The findings likely mirror the increasing prevalence of conduction abnormalities in the US and account for the better understanding that dual pacing better emulates normal cardiac physiology and atrioventricular synchrony .

Atrial fibrillation (AF) is the most common sustained arrhythmia worldwide, and its prevalence is expanding owing to advanced age and higher rates of chronic heart disease.1 The standard treatment for stroke reduction in patients with nonvalvular AF is anticoagulation. However, alternative therapy may be advisable in a certain subset of patients, owing to either previous failure of oral anticoagulation or presence of contraindications to anticoagulation.1 The left atrial appendage has been identified as the primary site of thrombus formation in more than 90% of patients with AF.2 The PLAATO3 study in 2002 was the first to demonstrate the use of a device to occlude the left atrial appendage for stroke reduction in patients with AF and provided the fundamental ground for future development in that field. Since its publication several percutaneous left atrial appendage occlusion (LAAO) devices have been developed and tested, including the Watchman, Amulet, and LARIAT, among others.4 The Watchman (Boston Scientific, Marlborough, MA) is the most extensively studied and is the only FDA-approved percutaneous LAAO device currently available in the United States.5 More than 100,000 devices have been implanted since it gained its approval in 2015.6 LAAO devices are approved for use in patients with nonvalvular AF who are not candidates for long-term coagulation with comparable outcomes in terms of risk of stroke, bleeding, and cardiovascular complications.7,8 Percutaneous LAAO has also been used in patients with recurrent cardioembolic stroke while on oral anticoagulation.9 Implantation of any intracardiac device carries the risk of device thrombosis and infection. However, risk of LAAO device infection is low owing to complete endothelialization. Currently, there are no guidelines regarding prophylaxis of bacterial endocarditis with Watchman device placement. Similarly, management of LAAO device infections remains uncertain, with no clear guidelines. We report a case of a 74-year-old man with Watchman device infection that was managed conservatively with a long course of antibiotics without the need for surgical extraction. Key Teaching Points • Left atrial appendage occlusion devices, despite endothelialization, can carry a late risk of device-related infective endocarditis. • Review of literature suggests role of transesophageal echocardiogram in the diagnosis of left atrial appendage occlusion device infections. • While surgical extraction has been previously described, we report a case of successful antibiotic suppression at 6-month follow-up.

Outcomes from randomized controlled trials (RCTs) inform the latest recommendations on percutaneous coronary intervention (PCI) management of a short period of oral anticoagulation (OAC), a P2YWe examined and summarized the outcomes of bleeding and major adverse cardiac events (MACEs) from RCTs and meta-analyses, published between 2013 and 2022, comparing therapy with OAC and a P2YData comparing dual therapy with OAC and a P2YThe addition of aspirin to OAC and a P2Y

Abstract: In-stent restenosis (ISR) is a recognized complication following percutaneous coronary intervention in which the luminal diameter is narrowed through neointimal hyperplasia and vessel remodeling. Although rates of ISR have decreased in most recent years owing to newer generation drug-eluting stents, thinner struts, and better intravascular imaging modalities, ISR remains a prevalent dilemma that proves to be challenging to manage. Several factors have been proposed to contribute to ISR formation, including mechanical stent characteristics, technical factors during the coronary intervention, and biological aspects of drug-eluting stents. Presentation of ISR can range from asymptomatic to late myocardial infarction and could be difficult to differentiate from acute thrombus formation. No definite guidelines are present on the management of ISR. In this review, we will discuss the mechanisms underlying ISR and provide insight into patient-related and procedural risk factors contributing to ISR, in addition to highlighting common treatment approaches utilized in the management of ISR.

Abstract: Cardiotoxicity from chemotherapy regimens has been long reported. However, the understanding of cardiac side effects of biological therapies is rapidly evolving. With cancer patients achieving higher life expectancy due to the use of personalized medicine and novel targeted anticancer agents, the occurrence of cardiotoxicity is becoming more significant. Novel biological therapies include anti-HER2 antibodies, tyrosine kinase inhibitors, bruton kinase inhibitors, antivascular endothelial growth factors, proteasome inhibitors, immunomodulator drugs, and immune checkpoint inhibitors. Potential cardiovascular toxicities linked to these anticancer agents include hypertension, arrhythmias, QT prolongation, myocardial ischemia and infarction, left ventricular dysfunction, congestive heart failure, and thromboembolism. Cardiac biomarkers, electrocardiography, echocardiography and magnetic resonance imaging are common diagnostic modalities used for early detection of these complications and timely intervention. This review discusses the various types of cardiotoxicities caused by novel anticancer biologic agents, their molecular and pathophysiological mechanisms, risk factors, and diagnostic and management strategies that can be used to prevent, minimize, and treat them.

Background Congestive heart failure (CHF) readmissions are associated with substantial financial and medical implications. We performed a descriptive study to determine demographic, clinical, and behavioral factors associated with 30-day readmission. Materials and methods Patients hospitalized with CHF at William Beaumont Hospital in Royal Oak, MI, from March 2019-May 2019 were studied. Response to heart failure knowledge and self-care questionnaires along with the patients’ demographic and clinical factors were collected. Thirty-day readmission to any of the eight hospitals in the Beaumont Health System was documented. Results One-hundred ninety-six (196) patients were included. The all-cause 30-day readmission rate was 23%. A numerical higher rate of readmissions was observed among males (23.7% vs 22.2%), current smokers (27.3% vs 22.9%), and patients with peripheral vascular disease (PVD; 28.9% vs 21.2%), diabetes mellitus (DM; 26.4% vs 18.9%), hypertension (HTN; 26.4% vs 10%), coronary artery disease (CAD; 24.6% vs 19%), and prior history of cerebrovascular accident (CVA; 28.9% vs 21.2%) (p>0.05). Reduced left ventricular ejection fraction (LVEF) was associated with higher readmissions (24.4% vs 20.5%, p=0.801). Patients with the highest reported questionnaire scores corresponding to better heart failure knowledge and self-care behaviors at home were readmitted at a similar rate compared to those scoring in the lowest interval (25%, p=0.681). Conclusion Though statistically insignificant due to the limitations of sample size, a higher percentage of readmissions was observed in male patients, current smokers, reduced LVEF, and higher comorbidity burden. Better reported patient self-care behavior, medication compliance, and heart failure knowledge did not correlate with reduced readmission rates. While the impact of medical comorbidities on 30-day readmissions is better established, the role of socioeconomic factors remains unclear and might suggest a focus for future work.

The use of nasopharyngeal (NP) swab sampling for the detection of various respiratory pathogens has been a standard procedure in medicine for many years. While this is a fairly common procedure, there has been a significant increase in utilization recently due to the SARS-CoV-2 pandemic. We describe a case of a 40-year-old SARS-CoV-2 positive patient with no prior cardiac history who developed asystole while an NP swab was being used to obtain a sample for a SARS-CoV-2 assay. Return of normal sinus rhythm was achieved with chest compressions alone. The incident was deemed to have been an exaggerated vagal response to intranasal stimulation; better known as the trigeminocardiac reflex. This is the first reported case describing asystole during use of an NP swab. This case occurred in a patient with no known cardiac disease and highlights the potential importance of the arrhythmogenic nature of COVID-19 that could potentiate the vagal response in susceptible individuals undergoing NP sampling.

Celiac plexus block (CPB) has been widely used as a treatment option for chronic intractable abdominal pain resulting from intra-abdominal malignancies as well as benign conditions. Complications resulting from CPB have been long reported and include diarrhea, back pain, paraplegia, postural hypotension, pneumothorax, and local anesthesia toxicity. Diarrhea and postural hypotension are two most common complications with studies reporting incidences occurring in 44% to 60% and 10% to 52% of patients, respectively. Diarrhea is most often transient, resolving within 48 hours; however, literature reports cases in which diarrhea was chronic, debilitating, and in some instances life threatening. Persistent diarrhea proves difficult to treat. We report a case of a 76-year-old male with unresectable pancreatic adenocarcinoma who underwent computed tomography-guided CBP complicated by persistent diarrhea and fecal incontinence. After conventional antidiarrheal failed to improve the symptoms, octreotide proved to be beneficial and the patient reported significant improvement in symptoms.

Takotsubo cardiomyopathy (TCM) is characteristically associated with left ventricular apical ballooning and regional wall motion abnormalities that predispose to the formation of left ventricular (LV) thrombi and subsequent thromboembolic events (VTE). There is limited data about the risk factors of developing stroke in the absence of LV thrombi in patients with TCM. Identify risk factors that predispose patients with TCM to develop VTE and stroke. We retrospectively reviewed all patients admitted with a primary diagnosis of stress induced or Takotsubo cardiomyopathy at a large tertiary care center from 2005 to 2019. Patients who met the echocardiographic criteria of TCM, had resolution of WMA on repeat echocardiogram, did not have coronary artery disease if angiography was performed and survived for3 months after index presentation were included in the analysis. Patients were followed for up to a period of 1 year. Multivariate analysis was performed to identify predictors of thromboembolism. Among the 400 patients who presented with TCM, 146 patients were included in the analysis. A total of 13 patients (8.9%) had documented thromboembolic events. Patients with VTE more often had Atrial fibrillation (30.8% vs 6.8%, P = 0.018), higher LV mass (224.5g vs 184g, P = 0.04), lower EF on presentation (31.5% vs 40%, P = 0.011) and were less likely to have undergone coronary angiography following diagnosis (23.1% vs 54.9%, P = 0.04). On multivariate analysis, atrial fibrillation (OR 9.15, CI 1.15-72.70) and low ejection fraction on admission (OR 0.88, CI 0.81-0.97) were independent risk factors for the development of VTE. Atrial fibrillation and low ejection fraction on presentation were associated with higher risk of developing thromboembolic events in patients with TCM.

We report a case of a 91-year-old Caucasian woman with a history of chronic lymphocytic leukaemia who developed acute hypoxic respiratory failure (AHRF) requiring intubation for less than 24 hours after receiving rasburicase. Laboratory workup was significant for methemoglobinemia and acute anaemia, and blood film demonstrated evidence of oxidative haemolysis with bite cells. The patient was given a presumptive diagnosis of glucose-6-phosphate dehydrogenase (G6PD) deficiency and was managed conservatively with successful resolution of AHRF and stabilisation of haemoglobin level. Seven days after admission, she passed away due to subsequent complications; hence, follow-up G6PD level could not be obtained. Haemolytic anaemia and methemoglobinemia in the setting of recent rasburicase administration should raise clinical suspicion for G6PD deficiency. In non-emergent cases, patients should be screened prior to receiving rasburicase regardless of risk factors. Because rasburicase is often needed emergently, patients at high risk of tumour lysis syndrome should be screened early for G6PD deficiency.